BLOCKS OF THE UPPER LIMB & THORAX

PRESENTER- DR. RANJITH R THAMPI

MODERATOR- DR. ELDO ISSAC

REGIONAL BLOCKS• UPPER LIMB1. Interscalene Block2. Supraclavicular Block3. Infraclavicular Block4. Axillary Block5. Mid Humeral6. Distal Blocks

• THORAX1. Intercostal Block2. Paravertebral Block3. PEC 1 Block4. PEC 2 Block5. Serratus Anterior Plane

Block6. Intrapleural Block

UPPER LIMB BLOCKS

SURGERIES INDICATEDInterscalene Blocks- Shoulder, Clavicle, Arm

Periclavicular Blocks- Arm, Elbow, Forearm(Radial Nerve)

Axillary Blocks- Forearm and Hand

*Remember, extension of blocks reflect only cutaneous blockade. Muscular and Osseous Innervations are not strictly superimposed.

• BRACHIAL PLEXUSAnterior rami of the cervical nerves from C5 to T1. Pass through their respective intervertebral foramina and converge laterally and caudally to form the trunks of the brachial plexus.

• C5 and C6 unite to become the superior trunk, C7 forms the middle trunk and C8 and T1 converge to form the inferior trunk.

• BP runs between middle and anterior scalene muscles.

RELEVANT ANATOMY-

GENERAL

• Brachial Plexus runs between middle and anterior scalene muscles.

- Phrenic nerve passes between these muscles, runs ventrally to the anterior scalene muscle. A diaphragmatic twitch during interscalene block performed with a nerve stimulator indicates placement of the needle anterior to the plexus.- Recurrent Laryngeal nerve, more medial, also close to the plexus, mainly on the right side. Can be blocked by diffusion of local anesthetic.• Medially to anterior scalene muscle runs the cervical sympathetic

chain. Medially and dorsally lies the vertebral artery and central nervous structures, risk of injection into verterbral artery or epidural or intrathecal anaesthesia.• Caudally, the plexus overhangs the pleura and the subclavian vessel.

RELEVANT ANATOMY- GENERAL

• COLLATERALS OF THE BRACHIAL PLEXUS• Dorsal scapular nerve arises from C5 and passes through the

middle scalene muscle to supply the rhomboideus and levator scapulae muscles.• Long thoracic nerve supplying the serratus anterior arises from

C5,6,7 and also pierces middle scalene as it passes posterior to the plexus.• The suprascapular nerve participates to the shoulder sensory

innervation and provides innervation of the infra and supraspinatus muscles.

The spinal accessory nerve runs posterior to the brachial plexus over the middle and posterior scalene muscles. With a nerve stimulator, a contraction of the trapezius indicates placement of the needle posterior to the plexus.

RELEVANT ANATOMY- GENERAL

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INTERSCALENE BLOCK

KEEP QUESTIONS IN MIND • Territories concerned?• Tourniquet required? If yes, which level?• Can the shoulder/elbow be moved?• Is catheter technique indicated?• Any contraindication to scheduled approach?• Any need to associate 2 or more techniques?• Is it a day case surgery?

INTERSCALENE BLOCK• Puncture is performed in the interscalene groove,

between anterior and middle scalene muscles.Block mainly concerns the trunks of plexus.

• Equipment1. Nerve stimulator2. 25mm insulated needle3. Sterile gloves4. Gauze and disinfectant solution5. Syringes with anesthetic local solution

LA- 0.5ml/Kg (max. 40mL) Bupivacaine 0.5% 20-40 ml Ropivacaine 0.5- 0.75% 20-40ml

ADDITIVES:-Clonidine(0.5-1 mcg/kg) prolongs block duration (3-4hrs).-Alkalinization helps reduce onset of time of block.- Epinephrine prolongs block but not more than clonidine.

INDICATIONS• Rotator Cuff Repair• Recidivant luxations• Total shoulder arthroplasty• Acromiopathies• Arthrolyses• Carcinologic surgery of the

shoulder• Physiotherapy of the shoulder

CONTRAINDICATIONS• Contralateral Phrenic palsy• Contralateral Pneumothorax• Contralateral Pneumonectomy• Any patient incapable of enduring a 25%

decrease in VC.A vital capacity of <1L is an absolute contraindication.

• Sensory defects in territory.• Bilateral surgery of the shoulder• Non specific- Coagulopathy, Infection at

site of injection, personality disorder.

INTERSCALENE BLOCK

• POSITIONPatient supine, head slightly turned away from side to be blocked.Arm along the body, slightly flexed. Patient awake.

• ANATOMICAL LANDMARKSPosterior head of SCM, easily palpated if the patient lifts the head against resistance.Behind this muscle, palpate interscalene groove between anterior and middle interscalene muscles. Better by asking patient to sniff.

• PUNCTURE POINTJunction of interscalene groove and line drawn passing through cricoid cartilage.(If lateral head of SCM is difficult to palpate, puncture 3cm behind the more prominent part of the SCM.

INTERSCALENE BLOCK

• PUNCTURENeedle inserted to skin, nerve stimulator twitched to 2mA. Needle is inserted into the interscalene groove at the level of the cricoid cartilage and advanced into the groove with a caudal, medial and slightly posterior direction. Motor responses are looked for.Failure to obtain motor response to nerve stimulation should prompt withdrawal of the needle and re-insertion in 5% to 10% angle anterior or posterior to the initial plane.

• INJECTIONWhen twitches are obtained at a current of 0.3 to 0.5mA, LA solution is injected in 3-5mL boluses, pausing to aspirate between each. Motor response disappears after first 1ml. Rapid incapacity.Sense of pins and needles in first 2 fingers(money sign).SURGERY can start 20-30mins after the block performance.

INTERSCALENE BLOCK

COMPLICATIONS• Respiratory Complications MOST COMMON

Ipsilateral Hemidiaphragm paresis, Recurrent laryngeal nerve block, Pneumothorax

• LA ToxicityInjection of LA in vertebral artery/ small cervical vessels.

• Neurological Complications.Horner’s syndrome- 18-20 % cases.Pourfour- Dupetit’s syndrome- exophthalmia, mydriasis, impossibility to close ipsilateral eye- rare- Due to irritation of cervical sympathetic chain.

• Epidural injection – Suspected if sensory defect of C/L UL occurs.Avoid by orienting needle medially, caudally and slightly dorsally.- Neuropathy due to intraneural injection or a direct trauma of the nerve by the needle.

INTERSCALENE BLOCK

SUPRACLAVICULAR BLOCKS

Greatest chance to block Brachial Plexus with only one injection.

KEEP QUESTIONS IN MIND • Territories ? Axillary (Inconsistent), Musculocutaneous, Median, Radial, Ulnar• Shoulder Surgery?- Interscalene better.• Elbow Surgery?- Infraclavicular block better suited.• Supraclavicular??? – Proximal upper arm surgery from superior third of humerus

to the elbow.

• Indwelling Catheter can be placed incase early mobilization is needed.

CONTRAINDICATIONSLOCAL

History of Ipsilateral:GENERAL

Carotid surgery Patients with respiratory Distress- risk of phrenic block in 30- 80% cases.

LN Surgery Contralateral phrenic nerve palsyRadiotherapy Coagulation defect

- Ambulatory surgery

• POSITIONPatient supine, arm along body, the head slightly rotated to opposite side. Physician on side to be blocked.• ANATOMICAL LANDMARKS

-EJV;-Medial aspect of trapezius insertion on the clavicle-top of Sedillot’s Triangle (limited by clavicle and 2 heads of SCM).• PUNCTURE POINT

Two lines drawn on patient: One from top of Sedillot’s Triangle to medial insertion of trapezius muscle on clavicle. Second is over EJV. Puncture at intersection of lines.

SUPRACLAVICULAR BLOCK

SUPRACLAVICULAR BLOCKS• Puncture is performed at intersection of the 2 lines.

Caudad and laterally directed. As superficial fascia is pierced, NS is set at 1.5mA with a 0.1 msec duration.

• Usual responseTriceps contraction, contraction of posterior forearm muscles. Biceps contraction is good response.

• MAXIMUM DEPTH- 1- 2.5 cm

LA- 0.5ml/Kg (max. 30mL)Catheter- Bolus- Bupivacaine 0.25% 20ml/8Hr Continuous injection of ropivacaine 0.2% 7-10ml/Hr

• Catheter not to be advanced more than 2cm.

ADDITIVES:-Clonidine(0.5-1 microgram/kg) prolongs block duration (3-4hrs).-Alkalinization helps reduce onset of time of block.- Epinephrine prolongs block but not more than clonidine.

SUPRACLAVICULAR BLOCKCOMPLICATIONS

IMMEDIATE OTHERSDiaphragramatic I/L palsy- phrenic nerve Recurrent Laryngeal nerve blockPneumothorax Claude Bernard Horner syndromeIntravascular injection

Other Named Techniques for Supraclavicular Block- Kullenkampf, Winnie-s paravascular, Dupre & Danel, Dalens, Browns, Pham- Dang ISCM

INFRACLAVICULAR BLOCKS

INFRACLAVICULAR BLOCKS• Nerves invovled: Axillary, Musculocutaneous, Median, Ulnar, Radial, Median antebrachial

and brachial cutaneous nerves.

• INDICATIONS:Anesthesia of upper arm, from shoulder to the hand.Suitable for surgeries of Distal arm, elbow, forearm, wrist.

• Short Procedure and Ambulatory Surgery- Mepivacaine 1-2%

• Long Surgical Procedure- Ropivacaine 0.5% to 0.75%, if long duration postop analgesia needed.

• VOLUME TO INJECT:Single injection technique- 30-40 mlMultiple Injections technique- 20-25 ml

• POSITIONPatient supine, arm along body, the head slightly rotated to opposite side. Physician on side to be blocked.

• ANATOMICAL LANDMARKS-Clavicle and Coracoid process are drawn on the skin.

• PUNCTURE POINTSite is drawn 2cm caudad and 1cm medial to coracoid process. Thus, site is in the deltopectoral groove.

Needle progression must be very careful to avoid perforation of axillary artery.

INFRACLAVICULAR BLOCKS

INFRACLAVICULAR BLOCKS• TECHNIQUES: Vertical Infraclavicular Block, Coracoid Block, Modified Raj• CATHETER INSERTION: After anesthetising skin, needle is inserted at puncture

site, PN Stimulator activated and set up at an intensity of 1.5 mA and frequency of 1Hz. Needle slowly driven in, perpendicular to skin. While progressing, search for evoked motor response.

*If evoked response is stimulation of musculocutaneous nerve(elbow felxion), needle tip is too superficial and too medial. Redirect more medially.*Median nerve or a radial nerve evoked motor response is more reliable(flexion and pronation of wrist).

• Reduce intensity and inject LA only when intensity is equal to or below 0.5 mA. Inject 1 ml and motor response will disappear immediately.

AXILLARY BLOCKLack of serious complications, Good Analgesia

AXILLARY BLOCK• INDICATIONS:

Anaesthesia of Hand, Wrist, Forearm surgery of longer duration in bloodless field• Landmarks:

Pulse of Axillary Artery, Coracobrachialis muscle, P.major muscle, Biceps muscle, Triceps muscle• Nerves involved:

Reliably blocks the median and radial nerves (but not the axillary and musculocutaneous – leaves the brachial plexus at the level of the coracoid process)

• POSITIONPatient placed in supine position with the head facing away from the side to be blocked. The arm abducted to form an approximate 90° angle in the elbow joint

• ANATOMICAL LANDMARKScourse of the axillary artery of the medial upper arm can be palpated dorsad from the medial bicipital groove. 

• PUNCTURE POINTSlightly above the axillary artery, at the highest point in axilla and slightly beneath the pectoralis major muscle which borders the axilla to the ventral.

AXILLARY BLOCK

-Needle is inserted parallel to the axillary artery at a 30°-angle to the skin. Contractions are sought in the area of the median nerve, or even better, of the radial nerve. Once the threshold current is reached, 40-50 ml of the local anaesthetic are injected. -Under no circumstances should the anaesthetic be injected if the musculocutaneous nerve has been stimulated, since at this height it has already left the neurovascular sheath and runs within the coracobrachialis muscle.

AXILLARY BLOCK SUMMARYThe most important landmark is the axillary artery, as the neurovascular bundle is oriented reliably around it – median nerve superiorly, ulnar nerve inferiorly, radial nerve posterior/lateral

Attempt to block the radial nerve first, as it is deepest and hardest to access – 10 – 15 cc should be adequate at each nerve, however each perineural injection makes visualization more difficult (hence starting with the deepest)Terminal nerves are difficult to visualize, and at the level of the axillary artery, oftentimes the median nerve is the only one visible – in this instance, deposition of local anesthetic circumferentially surrounding the axillary artery will result in a successful block

SupplementationThe intercostobrachial nerve, originating from the T2 intercostal, is often blocked by the local wheal over the axillary artery in this approach, however to ensure complete blockade, an additional 1-2 mL of local anesthesia can be added superficially around the palpable axillary pulse. Themusculocutaneous nerve can be blocked either by injecting into the coracobrachialis muscle or at the lateral, superficial aspect of the antecubital fossa just above the interepicondylar line

AXILLARY BLOCKCOMPLICATIONS AND TECHNIQUES TO AVOID THEM

MIDHUMERAL BLOCKSAims to anesthetize each nerve separately

MIDHUMERAL BLOCKS• Site of needle entry is the junction between the upper 1/3 and lower 2/3

of the arm. Terminal nerves of the brachial plexus are separated at this location. The median and ulnar nerves are found superficial and adjacent to the brachial artery, the musculocutaneous nerve under the biceps muscle belly and the radial nerve posterior to the humeral shaft.

MIDHUMERAL BLOCKS• NERVE LOCALISATION

• Place the transducer on the upper 1/3 of the arm to obtain a transverse view of the brachial artery in an outstretched arm.

• Identify the triceps, biceps and coracobrachialis muscles surrounding the artery.

• The median and ulnar nerves are expected to be superficial (often within 1 cm from the skin surface) and adjacent to the brachial artery. They often have a honey comb appearance and are heterogeneous in echogenicity.• Identify the musculocutaneous nerve between the biceps and coracobrachialis muscles. This nerve appears predominantly hyperechoic.• The radial nerve is not usually visualized at this level since it lies posterior to the humeral shaft.

MIDHUMERAL BLOCKS• NEEDLE INSERTION

• Ultrasound guided midhumeral block is considered a BASIC skill level block because this is a superficial block.

• Insert a 5 cm 22 G insulated needle parallel to the long axis of the transducer inline with the ultrasound beam (in plane approach).

• • Visualize the median, ulnar and musculocutaneous nerves in transverse view.• Identify the pulsatile brachial artery which is anechoic. Apply firm transducer pressure to collapse surrounding venous structures.

• The needle should be inserted at a shallow angle because the median and ulnar nerves are both superficial. As the needle travels in the same plane as the ultrasound beam, the path of advancement can be visualized in real-time as the needle approaches the target nerves.• Inject LA to achieve circumferential spread.

DISTAL BLOCKSuseful for minor surgical procedures within a single nerve distribution, such as wound exploration or small laceration repair

The three major peripheral nerves of the upper extremity (radial, median, and ulnar) may all be blocked at the level of the elbow. • Because of its location within the ulnar groove, the ulnar nerve has the most reliable

landmarks. The ulnar groove is palpated between the medial epicondyle of the humerus and the olecranon process. Ulnar nerve blockade at this level provides sensory blockade to the medial aspect of the hand, including the fifth digit and the medial half of the fourth digit.

• The brachial artery is the landmark for median nerve blockade at the level of the elbow. The median nerve lies just medial to the artery and may be blocked utilizing paresthesia, nerve stimulation, or ultrasound guidance based on this landmark. Median nerve blockade is useful for the anterolateral surface of the hand, including the thumb through middle finger.

• The radial nerve lies between the brachialis and brachioradialis muscles, 1 to 2 cm lateral to the biceps tendon. Using the biceps tendon as a landmark, the radial nerve can be blocked using paresthesia, stimulator, or ultrasound-based techniques. The radial nerve block at this level provides sensory anesthesia to the dorsolateral aspect of the hand (thumb, index, middle, and lateral half of the ring finger) up to the distal interphalangeal joint.

RELEVANT ANATOMY- GENERAL

DISTAL BLOCKS

AT THE ELBOW• Radial nerve. Identify the biceps tendon. Insert the

needle lateral to the tendon and above the antecubital crease. The nerve lies within the groove between the tendon and the brachioradialis muscle. Two excellent localization cues are paresthesia and motor response (finger/wrist extension) elicited by a nerve stimulator. Inject 5 to 7 mL of local anesthetic.

• Median nerve. Insert the needle at the antecubital crease, just medial to the palpated brachial pulse. When a paresthesia or motor response (finger/wrist flexion or hand pronation) is elicited, usually at 1- to 2-cm depth, inject 5 to 7 mL of local anesthetic.

• Ulnar nerve. With the elbow flexed at mid-range, insert the needle into the ulnar groove 1 to 3 cm proximal to the medial epicondyle. Take care to avoid excessive injection pressure or intraneural injection in this relatively tight space. Limit local anesthetic injection to 4 or 5 mL.

AT THE WRIST• Radial nerve. Make an injection along the lateral

border of radial artery 2 cm proximal to the wrist. Then extend the injection dorsally over the border of the wrist, covering the anatomic snuffbox. Injection of 5 to 7 mL of local anesthetic is usually sufficient.

• Median nerve. Identify the tendons of the flexor palmaris longus and flexor carpi radialis by flexing the wrist during palpation. Insert the needle between the tendons 2 cm proximal to the wrist flexor crease, posteriorly towards the deep fascia. Inject 3 to 5 mL of local anesthetic while withdrawing the needle.

• Ulnar nerve. Ulnar pulse is difficult to appreciate in many patients. A practical approach is to insert the block needle just proximal to the ulnar styloid process. After aspiration to confirm that the needle is not within the ulnar artery, inject 3 to 5 mL of local anesthetic.

THORACIC LEVEL- BLOCKS

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INTERCOSTAL BLOCK

INTERCOSTAL BLOCKEssentials•  Indications: thoracic or upper abdominal

surgery, rib fractures, breast surgery•  Landmarks: angle of the rib (6-8 cm

lateral to the spinous process)•  Needle insertion: Under the rib with

approximately 20-30° cephalad angulation

•  Target: needle insertion 0.5 cm past the inferior border of the rib

•  Local anesthetic: 3-5 mL per intercostal level

•  Complexity level: advanced

INTERCOSTAL BLOCK

Regional Anesthesia Anatomy• After emerging from their respective intervertebral

foramina, the thoracic nerve roots divide into dorsal and ventral rami. Dorsal ramus provides innervation to the skin and muscle of the paravertebral region; Ventral ramus continues laterally as the intercostal nerve. This nerve then pierces the posterior intercostal membrane approximately 3 cm lateral to the intervertebral foramen and enters the subcostal groove of the rib, where it travels inferiorly to the intercostal artery and vein.

• Initially, the nerve lies between the parietal pleura and the inner most intercostal muscle. Immediately proximal to the angle of the rib, it passes into the space between the innermost and internal intercostal muscles, where it remains for much of the remainder of its course.

• At the midaxillary line, gives rise to the lateral cutaneous branch, which pierces the internal and external intercostal muscles and supplies the muscles and skin of the lateral trunk. The continuation of the intercostal nerve terminates as the anterior cutaneous branch, which supplies the skin and muscles of the anterior trunk, including the skin overlying the sternum and rectus abdominis.

INTERCOSTAL BLOCK

Choice of Local Anesthetic• The performance of intercostal blocks is associated with relatively minor patient

discomfort, although needle contact with the periosteum can be uncomfortable. • A small dose of midazolam (2 mg) and alfentanil (250-500 µg) just before beginning

the block procedure is usually adequate to decrease the discomfort. • Excessive sedation should be avoided because positioning becomes difficult when

patients cannot keep their balance in a sitting position. • The first sign of successful blockade is the loss of pinprick sensation at the

dermatomal distribution of the nerve being blocked. The higher the concentration and volume of local anesthetic used, the faster the onset.

INTERCOSTAL BLOCK

Patient PositioningAn intercostal block can be performed with the patient in the sitting, lateral decubitus, or prone positions. With the patient in sitting or lateral position, it is helpful to have the patient's spine arched with the arms extended forward. Patients who are prone are best positioned for the block by placing a pillow under the abdomen and with the arms hanging down from the sides of the bed. This rotates the scapulae laterally and permits access to the angles of the rib above the level of T7.• For thoracotomy or upper abdominal incisions, an

estimate of the levels required for effective analgesia can be made after discussion with the surgeon as to the planned approach and length of incision.

• Analgesic blocks for rib fractures are planned based on the area of the injury. Typically, in addition to the estimated dermatomal levels, one additional level above and one below the estimated levels are also blocked.

COMPLICATIONS OF INTERCOSTAL BLOCK AND PREVENTIVE TECHNIQUES

PARAVERTEBRAL THORACIC BLOCK

Bolus of LA injected in the vicinity of the thoracic spinal nerves following their emergence from the intervertebral foramen.

PARAVERTEBRAL BLOCK

The resulting ipsilateral somatic and sympathetic nerve blockade produces anesthesia or analgesia that is conceptually similar to a "unilateral" epidural anesthetic block. Higher or lower levels can be chosen to accomplish a unilateral, bandlike, segmental blockade at the desired levels without significant hemodynamic changes.

Essentials• Indications: breast surgery, analgesia after

thoracotomy or in patients with rib fractures• Landmarks: spinous process at the desired thoracic

dermatomal level• Needle insertion: 2.5 cm lateral to the midline• Target: needle insertion 1 cm past the transverse

process•  Local anesthetic: 5 mL per dermatomal level

PARAVERTEBRAL BLOCK

Patient Positioning• The patient is positioned in the sitting or lateral decubitus (with the side to be blocked uppermost)

position and supported by an attendant. The back should assume knee-chest position, similar to the position required for neuraxial anesthesia. The patient's feet rest on a stool to allow greater patient comfort and a greater degree of kyphosis. The positioning increases the distance between the adjacent transverse processes and facilitates advancement of the needle between them.

Landmarks and Maneuvers to Accentuate Them• The following anatomic landmarks are used to identify spinal levels and estimate the position of the

relevant transverse processes:• 1. Spinous processes (midline)• 2. Spinous process C7 (the most prominent spinous process in the cervical region when the neck is

flexed)• 3. Lower tips of scapulae (corresponds to T7)

The tips of the spinous processes should be marked on the skin. Then a parasagittal line can be measured and drawn 2.5 cm lateral to the midline. For breast surgery, the levels to be blocked are T2 through T6. For thoracotomy, estimates can be made after discussion with the surgeon about the planned approach and length of incision.

COMPLICATIONS OF THORACIC PARAVERTEBRAL BLOCK AND

PREVENTIVE TECHNIQUES

PEC -1& 2 BLOCK

PEC I & II BLOCK• Paravertebral block was the most widely used technique of RA for breast surgeries.

However there is a risk of pneumothorax, inadvertant entry of needle into the vertebral canal, with consequent spinal cord trauma. Also it did not provide complete analgesia to the anterior chest wall, since the innervation was not exclusive to thoracic spinal nerves, but also brachial plexus, via medial and lateral pectoral nerves.They all rely on placing LA between the thoracic muscles

• Depending on the extent of surgery, the regional techniques chosen vary• PEC 1: LA injection between pectoralis major and minor at the 3rd rib level to block the lateral and medial pectoral nerves. Appropriate for surgery limited to pectoralis major. • PEC 2: a PECS 1 block, in addition a LA injection between pectoralis minor and serratus anterior at the 3rd rib level. By The latter injection blocks the lateral branch of the T2-4 spinal nerves, and possibly the anterior branch if sufficient LA penetrates the external intercostal muscles. By entering the axilla, the long thoracic nerve may also be blocked . Suitable for more extensive excisions e.g. tumour resections, mastectomy, axillary clearance.

PEC I & II BLOCKPECS “ THE ORIGINAL” BLOCK • Nerves Blocked- Lateral and medial pectoral nerves. • Indications: surgeries involving pecs major muscle. (breast expanders, traumatic chest injuries, portocath, pacemaker insertion). • LA: 10ml of the solution, to be deposited between pec major and minor at the 3rd rib level. • Technique – with the probe at the mid clavicular level and angled inferolaterally, first locate the axillary artery and vein. Next move the probe laterally until pectoralis minor and serratus anterior are identified. Locate the 2nd rib immediately under the axillary artery, then count the 3rd rib, and with further lateral probe movement, the 4th rib. • With the image centered at the level of the 3rd rib, advance the needle in- plane from medial to lateral in an oblique manner until the tip lies between pectoralis major and minor. Inject 10 mL LA between pectoralis major and minor.

PECS II “ MODIFIED” BLOCK

• Nerves blocked– T2-4 spinal nerves (including intercostobrachial nerve) and long thoracic nerve. • Indications (more extensive breast surgery involving serratus anterior and the axilla) tumour resection, sentinel node excision, axillary clearence, tissue expanders. • LA deposition – 20 mL LA injection between pectoralis minor (laterally) and serratus anterior at the 3rd rib level (this injection aims to enter the axilla to reach the target nerves, but LA will only enter the axilla if the fascia on the pectoralis minor lateral border is breached by surgery). • Technique – Perform sonography as for PECS 1 , but also identify the potential space between the lateral extent of pectoralis minor and serratus anterior. First perform a PECS 1 injection between pectoralis major and minor, then a second 20 mL injection between pectoralis minor and serratus anterior .

Thoracic wall blocks: Left=PECS 1 block, Middle=PECS 2 block, Right=Serratus plane block.

PECS BLOCK- Location for injection of LA

SERRATUS ANTERIOR BLOCK• SA: A single LA injection between latissimus dorsi and serratus anterior at the

5th rib level in the mid axillary line. This injection blocks the thoracodorsal nerve.

SERRATUS PLANE BLOCK • Nerve blocked: thoracodorsal , thoracic intercostal nerves. Lateral part of the

thorax is blocked. Position: supine patient, arms abducted, high frequency linear probe. With in plane technique from medial to lateral(or posterior) needle direction.• Indication: latissimus dorsi flap reconstruction, multiple rib fractures• LA: Probe in the midclavicular line in sagittal plane, to visualise the ribs and at the 5th rib the probe oriented in the midaxillary line, latissimus dorsi is superior and posterior, teres major superior, serratus in deep and inferior. • 2 planes are described for the block, superficial i.e above the muscle, deep: below the serratus anterior.

INTRAPLEURAL BLOCK• Interpleural block can provide analgesia over the chest wall and upper

abdomen and a single injection of local anaesthetic spreads to several intercostal nerves. Intrapleural and interpleural techniques have been used interchangeably but the latter is more appropriate.

• A single epidural catheter is most commonly inserted through a Tuohy needle at a level between T6 and T8, a point anywhere between 8 cm lateral to the posterior midline and posterior axillary line. A loss of resistance can be used to find the interpleural space. The catheter is placed 3-6 cm deep to the space and fixed. 20-25 ml of local anaesthetic (usually 0.25% bupivacaine) is then injected. The reported mean duration of analgesia is 2 to 18 hours (mean 7 hours). Continuous infusion dose is at a rate of 0.125 ml/kg/hour (2).

INTRAPLEURAL BLOCK• The technique appears to have a few recognised complications in

addition to pneumothorax, including intravascular injection, chest wall haematomas, pleural effusion, pneumothorax, Horner’s syndrome, L.A. toxicity and rarely LA spreading to epidural space.

Interpleural local anaesthetic administration is one of the different methods for providing perioperative analgesia in various upper abdominal surgeries like cholecystectomy, renal surgery v/l breast surgery. As well as providing analgesia for non surgical conditions like fractured ribs, cancer pain, herpes pain and pancreatic pain.

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